child welfare strategy group€¦ · staff responsible for resource family recruitment, development...

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Child Welfare Strategy Group

• Our assessment focused on Rhode Island’s over-reliance on group

placements, and found positive and innovative accomplishments toward

achieving your goals

• Your population of teens in group care is hindering progress toward your

goals, especially when compared to other jurisdictions

• There are three primary factors that impact costs in child welfare; Rhode

Island may have problems with all three

• Making the transition will require attention to DCYF and to your providers

Today I will report briefly on our assessment findings and respond to

discussion during the previous Task Force meetings with a national

perspective

1

Note: Most of the cross jurisdictional analyses use 2012 data from AFCARS, the most recent

data available.

The Annie E Casey Foundation was asked to assess the use of

congregate care in Rhode Island

Data Analysis • Analyzed state level longitudinal cohort and other data to understand priority issues and placement patterns

Policy &

Document Review

• Detailed review of DCYF policies

• Comprehensive review of recent state initiatives such as Rhode Island’s Federal IV-E Waiver, Phase 1 and Phase

2 of System of Care, Global Medicaid Waiver, and SAMHSA System of Care Expansion Implementation

• Review of legislative reports and relevant proposed legislation

Finance Review • Examination of budget process and assessment of opportunities to create cost savings to fund community services

Pathway Process

Mapping

• Detailed Pathway Process Mapping sessions with CPI and intake workers (10), and FSU workers in all four

regions (22)

Interviews &

Focus Groups

• Interviews and focus groups with state and regional leaders representing DCYF, State of Rhode Island General

Assembly, Family Court, Child Advocate, RIDE, Network lead agencies and FCCPs (45)

• Interviews and focus groups with DCYF frontline staff, including CPI, intake, placement, FSU, pre-permanency and

post-permanency supervisors (14), pre- and post-permanency workers (4) and DCYF attorneys (3)

• Observation of DCYF Placement Unit

• Interviews and focus groups with frontline staff in each Network, including NCCs (13), NCC supervisors (9) and

staff responsible for resource family recruitment, development and support (12)

• Interviews and focus groups with stakeholders, including provider agencies (5), GALs (2), and birth parent

attorneys (3)

• Interviews and focus groups with consumers, including youth (19), birth parents (7) and resource parents (9)

Surveys• Surveyed CPI, intake, placement, FSU, pre-permanency and post-permanency supervisors (36)

• Surveyed CPI, intake, placement, FSU, pre-permanency and post-permanency workers (111)2

3

DCYF has an innovative plan for children, youth and families, intended

to unify its services across divisions, while demonstrating a strong

commitment to System of Care principles

Phase I:

Prevention services offered through

Family Care Community

Partnerships (FCCP)

Phase II:

Development of the Family Care Networks

to re-balance the service array to focus less

on congregate care

• Community-based services and supports,

using the wraparound planning model to

prevent family involvement with DCYF, and to

support family preservation and child well-

being

• Each of the 4 FCCP’s are advised by a

Community Advisory Board

• Services include congregate care, treatment

foster care and community based services.

• The Title IV-E waiver to support traditional

placement services as well as enhanced family

support services and home and community-

based services for at risk and post placement

children, youth and families.

• The Global Medicaid waiver to support

evidence-based practices: Multi-Systemic

Therapy, Parenting with Love and Limits,

Strengthening Families and Preserving Family

Networks.

4

DCYF has developed many innovative systemic practices and been

awarded grants and waivers to support these practices

• Strong commitment to community and parent engagement and prevention, including development of

FCCPs, and commitment to Evidence2Success

• Development of and support for System of Care, and movement to the Family Care Networks

Contract with Foster Forward to support foster parents, and being a model site for services to older

youth with the Consolidated Youth Services Program which includes the Jim Casey Youth Opportunities

Initiative's ASPIRE services and the RICORP managed YESS Aftercare Services.

• Participation in the Juvenile Detention Alternatives Initiative to reduce the use of detention for youth

• RI DCYF is participating in the Pew Foundation's Result's First Initiative, which emphasizes the use of

evidence based practices and provides a cost benefit model for evaluating the effectiveness of services

and programming. RI DCYF will be one of the first states in the country to apply the Result's First

Initiative to both juvenile justice and child welfare programs.

• In 2014 Successfully completed the Program Improvement Plan as part of the Child and Family Service

Review.

• Partnering with the RI Family Court in the establishment of a Permanency Committee focused on

improving and supporting the permanency planning process for children, youth and families.

System-wide Innovations

DCYF has developed many innovative systemic practices and been

awarded grants and waivers to support these practices

Grants and Awards

• Implementation Cooperative Agreements with SAMHSA for the

expansion of the Comprehensive Community Mental Services for

Children and Their Families Program ($4 million over 4 years)

• Title IV-E waiver to add flexibility to the System of Care

• Diligent recruitment grant from federal government

• Grant for promoting well-being and adoption after trauma

5

6

Within its mission of partnering with families and communities to raise healthy children in

a safe and caring environment, the Department has articulated clear goals, strategies,

objectives, action steps and the rationale for change

DCYF has a clear vision and system improvement plan

for children, youth and families

1. Children and youth live in families

2. Continued improvements in Phases

I and II of System of Care

3. Staff are confident, competent and

empowered to provide the highest quality

of service to children, youth and families

Diligent foster care

recruitment

Right-sizing

and improving

congregate care

Wellness for staff

• Each of these

represents best practice

in the field today.

• The focus is on children

living with families, and

getting what they need

within the family setting.

• The focus on staff

wellness is recognition

of the importance of

“parallel process” in the

field of social work (i.e.,

staff treat clients the way

they are treated in the

workplace).

7

DCYF’s permanency outcomes are generally in line

with those of other states

Type of Discharge for Children Exiting Care State %

2010

State %

2011

State %

2012

51

State

Median

Reunified with parent, primary caretaker 60% 56% 54% 53%

Adoption 13% 15% 15% 21%

Guardianship 7% 9% 11% 6%

Living with other relatives 3% 2% 2% 4%

Emancipation and runaway 12% 14% 13% 10%

Transfer to another agency 4% 3% 4% 1%

NOTE: Exit cohort data over-represent children with short stays.










discussion during the previous Task Force meetings with a national

perspective

8

9

DCYF children in care are disproportionately children of color and are

more likely to be older youth

Compared to the general population of children

in Rhode Island, Black and Hispanic children are

over-represented in your system

Children entering care rate per 1,0001

Older youth account for nearly half of all entries

and enter care at a rate much higher than the

national median

1: AFCARS Foster Care Public Use Files FFY2012

2: State submitted AFCARS A/B Merged Files

3: Child Maltreatment 2012, U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families,

Children’s Bureau, 2013

1

3

Representation in the system by race

Children entering care in FFY2013 who were

13-20 years old 2

RI has 16.6 teens

entering care/1000 vs.

5.6/1000 nationally

Rhode Island had made significant progress in reducing the overall

population of children in care and in group placements,

but both have begun to increase this year

27%

Reduction

40%

Reduction

Source: State submitted AFCARS A/B Merged Files 10

11

Connecticut, almost three times the size of Rhode Island, has about

twice the number of kids in care and roughly the same number of kids

in congregate care

57%

Decrease

92% Decrease

79% Decrease

Connecticut had 3,428 children in care in June 2014.

Efforts to reduce the use of group care have succeeded.

Proportion of kids in congregate care = 13%.

Even with reductions in the use of group placements, DCYF has a

much greater percentage of kids in group settings than most states –

almost twice the national average

12Source: AECF KIDSCOUNT Data 2012

Rhode Island:

28%

Compared to states that count re-entries similarly, Rhode Island has

the second highest rate of re-entries, meaning that a large portion of

kids and families did not receive effective services

Source: AFCARS Data 9/30/2012

Rhode Island:

22%

Definition: C1.4: Of all children discharged from foster care to reunification in the 12-month period prior to the year shown, what percentage reentered care in less than

12 months from the date of discharge? RI is one of 16 states that count trial home visits as an exit from care , thus theoretically making the re-entry numbers higher. 11

14

Rhode Island has inordinate numbers of kids in group placements,

even among states with combined children’s agencies*

35.3%

27.4%

22.0% 21.7% 20.1% 19.9% 18.3% 17.2%14.1%

11.0%6.7% 6.4% 4.8%

50%

52% 50%

55% 58%

71%

57%

50%50%

71%

56%50%

50%

0%

10%

20%

30%

40%

50%

60%

70%

80%

2012 Congregate Care Usage1 and FMAP2 for States with Multi-Function Children’s Agencies

Congregate Care Usage

FMAP

1: AFCARS Foster Care Public Use Files FFY2012

2: “Federal Financial Participation in State Assistance Expenditures,” Federal Register, November 10, 2010 (Vol 75, No. 217), pp 69082-69084.

*Agencies with child welfare, juvenile justice and children’s mental health reporting to the same director.

When compared to other

states with combined children’s

agencies, Rhode Island’s use of

group placements is high.

Six of these 13 states have lower

per capita incomes than RI, as

measured by higher Federal

Medical Assistance Percentages

(FMAP).

*AECF KIDSCOUNT Data, 2012, the latest year for which comparable data are available

In comparison to jurisdictions of comparable size, Rhode Island had far

more kids in congregate care*

Children in Foster Care by Placement Type

“Other” includes Runaway, Supervised independent living, Trial home visit, and Pre-adoptive home

• Rhode Island does

a great job placing

kids with relatives,

but still has higher

proportions of kids

in group placements.

• Among kids 13 and

over, only 14% are

placed with relatives –

a missed opportunity.

• Kids placed with

relatives have a lower

probability of re-entry.

13

Child population 214,000**Child population 204,000** Child population 111,000**

**Kids Count, 2013 population estimates from US Census Bureau










discussion during the previous Task Force Meetings with a national

perspective

16

There are three variables that impact the bottom line in child welfare

• Volume: The number of kids entering care

• Duration: The length of time kids stay in care

• Acuity: The severity of needs of the kids entering care

17

Volume is related to the “front door” to the child welfare system

• Do DCYF workers have caseloads that allow them to undertake sound protective

investigations and oversight of in-home cases, such that they feel confident kids

will be safe at home?

• Are family support services available in the community to ensure that family

issues can be addressed while children remain at home?

18

ON

• DCYF caseloads are unacceptably high, primarily because of high vacancy

rates. When this happens, you can be sure that more kids will be removed from

their families.

• Cuts in the availability of preventive services have reduced options for

preserving families.

Duration is related to achieving timely permanency and attention to a

child’s best interests

• Do DCYF workers have caseloads that allow them to undertake ongoing

permanency efforts, even while a child is receiving therapeutic treatment?

• Do providers push DCYF or the networks to step children down to lower levels of

care when treatment has improved functioning?

19

• Staff caseloads are unacceptably high, primarily because of high vacancy rates.

When this happens, staff focus on the front end of the system, not children already in

placement, resulting in longer lengths of stay.

• Providers who have faced significant budget cuts are under huge pressure to keep beds

filled because their high fixed costs, and occupancy becomes critical to survival.

• Training and turnover rates may have hurt the Networks’ ability to manage care

effectively.

?

Acuity is related to the needs of the kids involved with the system

• Do DCYF workers have the skills and tools to make good decisions about which kids

should be referred to the Networks?

• Do DCYF workers have low level options (i.e., foster homes) for kids who do not need to

be referred to the networks, and the time to locate them?

• Do the networks have family-based clinical services available as needed? And incentives

to use them?

20

• Staff do not have valid assessment tools to help decide when kids need higher levels of

care.

• DCYF does not have a robust regular foster care system or ongoing capacity to

undertake family search and engagement.

• Providers who have faced significant budget cuts are under huge pressure to keep beds

filled because they must deal with fixed costs first, thus have been unable to develop

family and community based alternatives to residential care.

NO

Based on those three problems, three areas will be discussed

• Assessment: Assessment for the purpose of placement can be accurately

and efficiently undertaken, and data can be aggregated into a performance

management system able to answer the question: Is the child better off

because of the system’s intervention?

• Foster care: Having a robust foster parent recruitment, development and

support function that meets the needs of the kids entering care is always

cost effective.

• Meeting the needs of teens: Teens with behavior problems can be

effectively served in the community at far less cost than group placements.

21

Screening and assessment data is collected online

Kraus, D., Seligman, D., & Jordan, J.R., (2005). Validation of a behavioral health treatment outcome and assessment tool designed for naturalistic settings: The treatment

outcome package. Journal of Clinical Psychology, 61, 285–314.

Kraus, D., Boswell, J., Wright, A. Castonguay, L., & Pincus, A., (2010). Factor Structure of the Treatment Outcome Package for Children. Journal of Clinical Psychology, 66,

627-640.

English, Spanish, Portuguese, Chinese, German, Dutch, Haitian, Vietnamese, Cape Verdean

Easy-to-answer questions, all answered on the same reliable scale

(no training or clinical expertise needed)

Annie E Casey and The Duke Endowment have invested in an assessment

tool and performance management system that turns easy-to-collect

raw data into useful analyses

(This is a sample of the total set of questions)

22

23

The process and the reports allow 360 reviews of kids’ behaviors and can

provide caseworkers and care managers with new and important information

Note critical problems

unknown to caseworker

before getting this

report from foster

parent

o

For the first time ever, TOP data are telling us about the prevalence of

specific issues for children within the child welfare population

31

70

15

1

915

25 27

63

36

65

0%

10%

20%

30%

40%

50%

60%

70%

ADHDC CNDCT DEPRS MANIC PSYCS SLEEP SUICD SA VIOLN WORKF SCONF

Percent of teens in Cuyahoga County, Ohio with clinically

significant domain scores on initial assessment

(n=394, 37 (9%) had no clinically significant issues)

AD

HD

Co

nd

uct

De

pre

ssio

n

Ma

nia

Psych

osis

Sle

ep

Su

icid

e

Su

bsta

nce

Ab

use

Vio

len

ce

Wo

rk/s

cho

ol

Fu

nctio

nin

g

So

cia

l

Co

nflic

t

22

Very early outcome data from Cuyahoga County, OH are finally

answering the question: Is anyone better off because of the agency’s

or providers’ interventions? (n = 266)

Adolescent Data

n=266

0.86

2.51

0.04

-0.78

-0.09

-0.45

0.730.61

1.80

0.42

1.15

0.70*

2.09

0.01

-0.74

-0.13

-0.49

0.38

0.69

1.22

0.00*

1.01

-1.0

-0.5

0.0

0.5

1.0

1.5

2.0

2.5

3.0

ADHDCn=212

CNDCTn=223

DEPRSn=207

MANICn=183

PSYCSn=179

SLEEPn=195

SUICDn=193

SAn=189

VIOLNn=209

WORKFn=229

SCONFn=232

Average Initial Score Average Followup Score

2.09

General

Population

Norm

Sta

nd

ard

De

via

tio

ns fro

m N

orm

Yellow bars represent initial assessment scores and green bars represent follow up assessment scores; scores higher than “0”

are worse than the general population norm. Scores below “0” are better than the general population. Green bars lower than

yellow bars represent improvement over time.

23

While not yet statistically significant,

substance abuse services for teens

do not appear to be achieving improved

results yet.

*Statistically significant. Eight of the 13 domain scores for children 6-12 showed statistically significant improvements (n = 837).

Pro

vide

rs

Assertiven

ess

Inco

ntin

ence

Dep

ression

Psych

osis

Separatio

n

An

xiety

Sleep

Suicid

e

Eating

Diso

rders

Vio

lence &

A

ggressiveness

AD

HD

Co

nd

uct

Diso

rders

Man

ia

Social C

on

flict

Scho

ol

Fun

ction

ing

A

B

C ++ ++

D ++ ++

E ++ ++ ++

F ++

G ++ ++ ++ ++ ++ ++

H ++

I ++ ++

J ++

K ++

L ++

M ++ ++

N ++ ++

O

P ++ ++

Q ++ ++ ++ ++

R ++

S

T ++ ++ ++ ++

The TOP performance management process scientifically identifies

providers’ strengths and weaknesses in improving behavioral

health/well-being outcomes, which is useful for quality improvement

De-

iden

tifi

ed R

esid

en

tial

Pro

gram

s

24

*This table represents all children in residential care in the subject state, N = 1,174 over a 2 year period.

The report shows the effectiveness of residential treatment providers in achieving improvements in children’s behavioral health issues; the same analysis

works for all types of placements and providers.

KEY: Top 10% (++)Above average ()

Traditional foster care and kinship support are critical service areas

needing significant new investments, and can prevent the need for

higher cost services

• When caseworker vacancies are a problem, staff who recruit, develop and license foster

families, and staff used to undertake family search and engagement (or caseworker time

to do so) is inevitably sacrificed to deal with the front door.

• Staff to recruit, develop and license foster family homes, especially targeting the kids

entering care (teens) must be specialized and protected to assure the function is

undertaken well. (Teen family homes are found through targeted recruitment methods,

not advertising campaigns or partnerships with businesses.)

• Additional staff or contract funds may be needed to support foster families and kin

caregivers when they need help –

– 24/7 help in crisis situations

– help with behavioral issues.

• Staff to undertake family search and engagement, when reunification is not an option

should be available. They can get teens out of care and back to living with family. (DCYF

does a great job of kinship placements for younger kids, but not for teens.)

• Foster family stipend rates may need to be increased. 27

A national study completed in 2007 established Minimum Adequate

Rates for Children (MARC) in Foster Care

(Have you increased foster family rates since then?)

Hitting the Marc: Establishing Foster Care Minimum Adequate Rates for Children. Children’s Rights, National Foster Parent

Association, University of Maryland School of Social Work, 2007. The reports establishes Foster Care Minimum Adequate Rates for

Children (the “Foster Care MARC”) based on an analysis of the real costs of providing care, including the cost of providing food,

clothing, shelter, daily supervision, school supplies, personal incidentals, insurance and travel for visitation with a child’s biological

family. It was calculated by analyzing consumer expenditure data reflecting the costs of caring for a child; identifying and accounting

for additional costs particular to children in foster care; and applying a geographic cost‐of‐living adjustment, in order to develop specific

rates for each of the 50 states and the District of Columbia. It includes adequate funds to meet a child’s basic physical needs and cover

the costs of “normalizing” childhood activities, such as after‐school sports and arts programs, which are particularly important for

children who have been traumatized or isolated by their experiences of abuse and neglect and placement in foster care. 28

In 2007, to hit the MARC, rates needed to increase by:

Age 2 Age 9 Age 16

National Average 29% 41% 39%

Connecticut 0% 13% 14%

Massachusetts 56% 65% 56%

Maine 25% 36% 40%

New Hampshire 80% 89% 76%

Rhode Island 65% 99% 89%

Vermont 48% 53% 52%

In 2011, Casey looked at promising programs to prevent family disruptions

due to teen behavioral issues; reforms in New York state were noteworthy

New York City dramatically reduced

placements using gatekeeping, screening and

assessment and a tiered array of services,

which supported help to keep families

together

Erie County NY used a similar approach and

also emphasized inter-agency collaboration

and data analysis to manage utilization and

outcomes, with a focus on providing help to

parents and youth to stay together

29

Annual Placements to Residential Treatment of Youth with

Behavior Problems

Service Type

Services Delivered

in 2011

Information and Advocacy 2875 36%

Referrals to Other Services 2194 27%

Level 1 Crisis Stabilization 801

Level 2 Functional Family Therapy* 504

Level 3 Multi-Systemic Therapy* 228

Level 4 Multi-Dimensional Treatment Foster Care*

(Out of home 9 – 12 months)

245

TOTAL LEVELS 1 – 4 1778 22%

Families refused, withdrew or were being served elsewhere 1150 14%

Total families seen 7997 100%

In NYC, most families received information, advocacy and referrals; of those

served, only 22% required higher level, more intensive services

30* Evidence-based programs Chart compiled by authors based on data supplied by ACS FAP administration.

In Erie County, savings from placement reductions have been redirected into

community-based wraparound services to help parents and youth deal with

behavioral health issues at home together

By 2011, Erie County had saved almost

$12 million in residential treatment costs

The County chose to re-invest the

savings in order to serve more

youth and families with early

intervention services

31

1$2 M

1$4 M

$8 M

$10 M

$12 M

1 $6 M

Savings computed against reduced use of bed days from 2004 base level

Wraparound services for families and youth have promoted healthier family

relationships and prevented the need for family disruption.

Expenditures and clients served through

Community-based System of Care

Delaware, a state very similar to Rhode Island, also had a problem

related to teens with behavioral issues

31%

30

Teens experienced high rates of placement instability and institutional placements

– the system was not meeting their long term developmental needs.

The Delaware FAIR program was launched in 2013, based on NY’s

experience and has had great success diverting teens from out-of-

home placements

33

455 youth referred to

FAIR

104 returned to CW or

closed after assessment*

351 youth served after assessment

Of the 351 youth served by FAIR after assessment between 3/13 and 7/14,

91% of them have so far been diverted from out-of-home placements

*50 declined; 23 were sent back to CPS for safety issues; 31 were closed for lack of need

Still at home

The success of the FAIR program has contributed to the decline in the

number of teens in care and entering care, with more families able to

successfully manage teen behaviors at home

34



achieving your goals given resource limitations







discussion during the previous Task Force Meetings with a national

perspective

35

The development of alternatives to congregate care means re-tooling, and

shifts in the business models of your current group care providers

Help providers shift away from

their reliance on facilities

• You have a group of providers

currently providing congregate care

who have fixed costs, and employ

staff in their communities.

• You don’t want them to go out of

business; you want them to shift

their business models.

Help providers develop specialized

residential programs

• You still have significant numbers of kids

going out of state for treatment.

• When rates don’t keep up with costs,

providers will not/ cannot take the most

difficult kids, therefore kids more likely to

go out of state.

• (There will continue to be very limited need

for out of state placements.)

36

• You need a rate setting process based on actual costs, with room to increase

rates for providers to develop specialized services.

• You need a plan to close less therapeutic facilities, offering providers

opportunities to re-tool.

Current circumstances inhibit the ability of your providers to reduce

their commitment to congregate care

• Based on experience in other states, and the statements of providers at

the first Task Force meeting:

– Your rates do not allow the level of therapeutic interventions needed

for some of the kids needing high levels of care.

– Some of the most needy kids are sent out of state (but there will

always be some kids out of state).

– Your congregate care providers are serving many kids who could

remain in the community, and probably keeping them longer than

necessary.

– Your congregate care providers probably do not have the capacity to

shift away from residential care, without additional funding.

37

Assumptions about what you want to achieve:

38

• You want to serve kids close to home (in state);

• You want to keep your providers in business;

• You want to reduce the use of group settings;

• You want to keep families together when possible or serve kids in the most family-like settings.

What would I do in your shoes…

(But each will require more resources or a shift in resource allocation)

39

Assessment

• Install the TOP assessment and performance management system to start to understand

what kids need, what’s working, and who’s doing a good job at meeting those needs.

Caseloads

• Get DCYF caseloads down to reasonable levels, by making sure vacancies are filled, even if

it requires overfilling slots.

Foster and kinship families

• Invest in and protect staff for foster family recruitment, development and licensing, especially

focused on teens.

• Increase investment in foster and kinship family support.

Provider services

• Develop a program to divert teens with behavior problems from placement (like Delaware).

• Develop a rate setting process with residential providers to understand current funding

situation.

• Work with residential providers to decide which have capacity to take more difficult kids and

which should close. Work with both groups to shift their business models, which would

include rate increases, or funds to shift to community-based services.

child welfare strategy group€¦ · staff responsible for resource family recruitment, development...

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